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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 3-3 Candy cane stirrups in place.
Simultaneously lift both legs, flexing hips and knees to minimize
unhealthy abduction/adduction at knee and ankle joints, and place the feet
in stirrups such that one strap cradles fore- to midfoot and one strap
cradles heel (Fig. 3-4).
FIGURE 3-4 Proper positioning of the stirrup on the heel and midfoot, avoiding
pressure on the Achilles tendon.
If the knees or ankles are excessively torqued, the angle of the candy canes
at their bed attachment may be modified to bring them into good position
(Fig. 3-5).
FIGURE 3-5 Adjustment of the angle of the stirrups at the bed to bring legs and hips
into proper alignment.
LITHOTOMY WITH BOOT-TYPE STIRRUPS (EG, YELLOWFINS)
Perioperative Considerations
Boot-type stirrups provide better support for the joints of the legs and are
preferable to candy canes for cases >30 minutes in length.
Peroneal nerve injury is the most common positioning injury associated
with boot-type stirrups, resulting in a sensory neuropathy without motor
deficit, and utilizing proper technique is aimed at avoidance of pressure on
the lateral aspect of the tibial head to avoid this injury.
Pressure on the popliteal fossa should be avoided by rotating the boot
toward the floor such that the foot is flat in the bottom of the boot
(“standing in the stirrup”), taking pressure off of the posterior calf. Also
avoid stirrup boots that reach too high posteriorly into the popliteal fossa.
The leg can be moved up and down as needed during the case. Keeping
the knee low (close to in line with the hip) helps avoid interference with
laparoscopy in the upper abdominal field or with a low abdominal
incision. On the contrary, elevating the foot as high as possible provides
maximal access to the posterior perineum. The leg should be tested in all
anticipated positions prior to draping and inspected for safety in each.
When combining arm tucking with boot lithotomy, protection of the hands
using padding is essential to aid in prevention of traumatic finger injury
during movement of stirrups (see arm tucking).
Equipment
Bed attachment brackets
Right and left stirrups
Foam padding torn into two small squares and two large squares
Technique
Place brackets on the lowest portion of side rail of body portion of the
table and then secure boot-type stirrups firmly (Fig. 3-6).
FIGURE 3-6 Bracket for boot-type stirrups on the table near the table break.
Adjust the boots to be lying parallel and adjacent to leg portion of the bed
and move boots up on bars to position closest to hips, with boot toes
facing forward and soles of feet orthogonal to the bed. Boots should be
just slightly loosened on the bars so that they can be manipulated easily
but without unintentional slippage (Fig. 3-7).
FIGURE 3-7 Placing the legs into the boot-type stirrups.
Move the legs simultaneously into stirrups and remove/lower the foot of
the bed, as described earlier.
Place a large piece of foam padding between the lateral aspect of the
knee/lower leg and the stirrup, and place a small piece of foam padding
between the tubing of the pneumatic compression devices and the patient’s
foot to minimize pressure (Fig. 3-8).
FIGURE 3-8 Foam padding on the lateral aspect and by the pneumatic compression
device connection.
While standing at the end of the stirrup and supporting the leg with one’s
body, moderately loosen one stirrup boot and position it with the
following principles:
The foot, knee, and opposite shoulder should form a line.
There should be minimal to no pressure on the lateral knee/lower leg to
avoid peroneal nerve injury.
The plantar foot should sit flat in the bottom of the stirrup, and the
weight of the leg should be resting on this portion of the foot, not on
the posterior calf (Fig. 3-9).
FIGURE 3-9 Proper position of the heel in the boot-type stirrup.
The knee should be neutrally rotated, not outwardly or inwardly (Fig.
3-10).
FIGURE 3-10 Appropriate knee positioning in boot-type stirrups.
The knee should be flexed, but not excessively as to interfere with
surgery. The distance between the heel and the table should be
customized for each patient’s leg length (Fig. 3-11).
FIGURE 3-11 Knee flexion in boot-type stirrups.
A fully extended knee is at risk for overextension during surgery. If
significant Trendelenburg position is anticipated, prepare for ∼2-7 cm of
slippage cephalad that may cause knee and hip extension.
LITHOTOMY WITH SPLIT-LEG TABLE
Perioperative Considerations
Split-leg table provides enhanced support for the legs more similar to
supine position, minimizing risk of nerve, joint, or compartment injury
relative to other forms of lithotomy.
On the downside, split-leg positioning provides more limited access to the
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